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Informational Packet
nd
2 REISSUE
Changes to the Approved Program Capacity Process
Resulting from the Provider Settlement Agreement
ODP Communication Number: Packet 028-15
The mission of the Office of Developmental Programs is to support Pennsylvanians with developmental
disabilities to achieve greater independence, choice and opportunity in their lives.
ODP is reissuing this communication to provide clarification in the area of billing and to announce the
last day ODP will accept Approved Program Capacity change requests. See red font within the document
for language changes and /or additions.
AUDIENCE:
Qualified Waiver Residential Habilitation Service Providers licensed under 55 Pa.
Code Chapter 6400, Administrative Entities (AE), Supports Coordination
Organizations (SCO) and All Interested Parties
PURPOSE:
This ODP communication is intended to inform all interested parties of the
procedures to follow to implement the changes made to the Approved Program
Capacity (APC) process resulting from the provider Settlement Agreement,
effective October 28, 2014.
NOTE:

The procedures detailed in this communication apply only to providers who have signed
and submitted the Provider Settlement Agreement addendum. The addendum will be
made available to applicable providers in the near future. Any adjustment made that
results in changes to APC, pursuant to the procedures of the Settlement Agreement, will
automatically be end dated on June 30, 2015 and the APC that was previously approved
for the service location will be reinstated.

Please note, changes made to APC do not represent an adverse action to the
participant(s). APC changes are administrative in nature, time limited and relate only to
the Provider Settlement Agreement.
REISSUE DATE: June 2, 2015
Informational Packet # 028-15: REISSUE (2ND)
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BACKGROUND
The Department of Human Services (formerly the Department of Public Welfare) entered into a
Provider Settlement Agreement effective October 28, 2014. This communication will address
Paragraph #5 of the Settlement Agreement which specifies the following:
Excerpt from the Provider Settlement Agreement:
“5. The Department, for the period July 1, 2014 through June 30, 2015, will amend its
policies to temporarily reclassify residential capacity related to transitional bed openings
as of the date the opening occurs. The Department will process any reclassification
change expeditiously but in no case later than forty-five (45) days after a request is
received. The provider may bill retroactively to the date the transitional opening
occurred. All residential capacity for an individual home shall be restored to the
capacity level that existed prior to the application of the temporary policy effective as of
the date of the policy changes. During the effective period of this policy, a provider may
not act arbitrarily and capriciously in its refusal of a referral. For the period referenced
above, this Agreement controls the review, approval and denial of reclassification
requests.”
NOTE: For purposes of this communication and the settlement, the term “transitional bed
opening”, as indicated in the above paragraph, is considered a “residential vacancy”. The term
“residential vacancy” is defined in ODP Informational Packet 098-12, titled “ODP Procedure for
Residential Vacancy Management”. According to the communication, a residential vacancy
occurs when there is:


A change in an individual’s residential service provider OR a change in service,
Disenrollment from the waiver (death, moving out of state).
DISCUSSION
Procedures to Request a Change to Approved Program Capacity (APC)
The table on the following page details the provider action steps required to request a change
to APC as a result of the provider Settlement Agreement. The table also includes the AE and
ODP Regional Waiver Capacity Manager’s (WCM’s) role in this process.
The deadline for an Approved Program Capacity change request is July 15, 2015.
REISSUE DATE: June 2, 2015
Informational Packet # 028-15: REISSUE (2ND)
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ACTION/ROLE DESCRIPTION
STEPS
STEP 1
STEP 2
ACTION
Complete
DP 1024
Submit
DP 1024
PROVIDER
In accordance with ODP Informational Packet
098-12, titled “ODP Procedure for Residential
Vacancy Management”, as soon as the provider is
aware of an existing or potential residential
vacancy in a licensed Chapter 6400 residential
setting, the provider must complete the ODP
approved, Provider Vacancy Notification Form,
DP 1024. A copy of the DP 1024 is attached to this
communication and can be found at:
http://www.odpconsulting.net/resources/odpforms/
The completion of the DP 1024 is a required
document when requesting a change to APC.
The provider will submit the DP 1024, via e-mail,
to the AE/county of registration where the
individual, who created the vacancy, was
registered. The provider should copy the
appropriate ODP Regional WCM on the e-mail.
Submission of the DP 1024 should be completed
within three (3) business days of becoming aware
of the vacancy.
STEP 3
Track
Referrals/
Document
Decisions
The provider should track all incoming referrals
and document all decisions related to the vacancy
documented on the DP 1024 form. This
information shall be forwarded to the ODP
REISSUE DATE: June 2, 2015
Informational Packet # 028-15: REISSUE (2ND)
ODP
WAIVER CAPACITY MANAGER
AE
N/A
N/A
The ODP Regional WCM receives a copy
of the DP 1024, via e-mail, that the
provider submitted to the AE.
The ODP Regional WCM will review the
vacancy information found on the DP
1024, contact the AE where the
individual who created the vacancy was
registered and discuss with the AE of
registration if they can fill the vacancy. If
the vacancy cannot be filled at this the
time, the ODP Regional WCM will enter
the information found on the DP 1024 on
the Statewide Vacancy Report.
As needed, request referrals and
decisions that were documented by the
provider.
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Receives the completed DP 1024 from
the provider via e-mail.
The AE is contacted by the ODP
Regional WCM. The AE must identify an
individual who has needs that will most
appropriately be addressed by the
existing residential vacancy and is
required to provide that information to
the ODP Regional WCM within five (5)
calendar days.
N/A
ACTION/ROLE DESCRIPTION
STEPS
ACTION
STEP 4
Complete and
Submit APC
Change
Request Form
PROVIDER
ODP
WAIVER CAPACITY MANAGER
Regional WCM upon request.
In order for a provider to request a change to
their APC, a provider must have already signed
and submitted the Provider Settlement
Agreement addendum. To request a change to a
service location APC, the provider must:
WCM receives a completed APC Change
Form1 from the provider. The WCM may
also receive the DP 1024 from the
provider if one is not on file.
Submit the request form titled “Request for
Change in Established Approved Program
Capacity (APC) per the 2014 Provider Settlement
Agreement”, referred to as the “APC Change”
form, to the appropriate ODP Regional Waiver
Capacity Manager (WCM)1.
AE
The ODP Regional WCM has 45 calendar
days from the date they receive the APC
Change Request form to respond to the
provider with a determination.
N/A
Have a Provider Vacancy Notification Form, DP
1024, on file or submit a completed DP 1024 form
with the APC change form. Approval will not be
granted for a change involving a current vacancy
until the DP 1024 has been submitted.
STEP 5
Notification of
APC Change
Approval
STEP 6
Void Previously
Submitted
Claims
The deadline for an Approved Program Capacity
change request is July 15, 2015.
Provider receives the APC Letter, via e-mail, from
the ODP Regional WCM indicating their APC
change request was approved.
If the APC change is retroactive, the Provider
must void ALL PROMISeTM billings that were
submitted from the first day of the requested
APC change through the last day billed for the
The ODP Regional WCM will notify the
provider that APC change has been
approved using the letter template found
at the end of this communication.
Available to provide technical assistance
to the provider
1
The AE is copied on the ODP Regional
WCM’s e-mail to the provider which
indicates that the provider’s APC
change request has been approved.
N/A
The “Request for Change in Established Approved Program Capacity (APC) per the 2014 Provider Settlement Agreement” request form, also referred to as the “APC Change” form, is posted in a
user friendly format on www.odpconsulting.net > Resources > ODP Forms. Providers also have the option to print out the form located on page 14 of this communication, complete the form by
hand, scan it and e-mail it to your ODP Regional Waiver Capacity Manager.
REISSUE DATE: June 2, 2015
Informational Packet # 028-15: REISSUE (2ND)
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ACTION/ROLE DESCRIPTION
STEPS
ACTION
PROVIDER
ODP
WAIVER CAPACITY MANAGER
AE
current APC. This is necessary because HCSIS
does not allow a change to be made to the date
span for a service on the ISP when billings have
already been made against it. Billings for both
eligible and ineligible residential procedure codes
must be voided before a resubmission is done
AND before a new service is authorized on the
individual’s plan.
STEP 7
STEP 8
Notify AE, Via Email, That
Claims Have
Been Voided
Update the
SSD/Revise ISP
NOTE: When a claim is voided, a credit is applied
to the provider’s service location in PROMISeTM.
Future billings to PROMISeTM, which are approved
for payment for that service location, will be
reduced by the outstanding credit. Voids and
credit depletions will be reflected on the
provider’s remittance advice.
The Provider must e-mail the affected AE(s) and
communicate to them that all of the participant’s
claims have been voided. The ODP Regional WCM
should be copied on the e-mail to the AE(s).
After the provider voids the applicable claims in
PROMISeTM, the provider should update the
Services and Supports Directory (SSD) in HCSIS by
adding the new services (W codes for eligible and
ineligible) to the service location using the start
date AND end date found in the APC letter.
REISSUE DATE: June 2, 2015
Informational Packet # 028-15: REISSUE (2ND)
Receive notification from the provider
that the applicable claims have been
voided in the claims processing system
and the AE(s) has been informed.
Available to provide technical assistance
to the provider
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AE is informed that applicable claims
have been voided.
AE notified by provider that their SSD
has been updated to reflect the
services and timeframe found on the
APC Determination Letter.
1. End date both the current eligible
and ineligible residential service
authorizations for the day prior to
the new APC start date. For partial
year adjustments, units will need
to be adjusted accordingly.
2. Enter the new eligible and
ineligible residential services with
the new start date and the new
ACTION/ROLE DESCRIPTION
STEPS
ACTION
PROVIDER
STEP 9
Notification
Plan Updated
Provider notified by AE that the ISP has been
updated and claims can now be billed.
STEP 10
Validate plan
updates
Submit Claims
Obtain new service authorization notice from
HCSIS and confirm accuracy prior to billing.
Bill for services per the new service
authorizations found in HCSIS.
In order to reestablish APC to the level it was
prior to the reduction, based on the Settlement
Agreement, the Provider must follow the
STEP 11
STEP 12
Reestablish
Provider APC
Levels
REISSUE DATE: June 2, 2015
Informational Packet # 028-15: REISSUE (2ND)
ODP
WAIVER CAPACITY MANAGER
ODP Regional WCM notified by the AE
that the ISP has been updated.
AE
end date identified in the APC
Determination letter from ODP.
Do the same for partial year
adjustments but also add units.
3. Upon completion of the revision to
the authorized services, add
language to the Plan Comments
section of the ISP. This is accessed
by clicking on the Add/New
Comments link at the bottom left
of ISP submission page. The
hyperlink opens up a text box to
enter comments. The AE should
enter the following language: “This
is a time limited administrative
action related to a Provider
Settlement Agreement and does
not represent an adverse action to
the participant”. After entering the
comments, the plan can be
submitted.
4. AE must approve and authorize the
ISP(s).
Notify the ODP Regional WCM, SC and
provider that the ISP has been updated
and changed.
N/A
N/A
N/A
N/A
N/A
N/A
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ACTION/ROLE DESCRIPTION
STEPS
NOTE
ACTION
Impact when no
other changes
requested to
APC During
FY 2014-2015
PROVIDER
procedures in the ODP Approval of Residential
Service Locations and Approved Program
Capacity, Informational Packet 055-12, to
increase the APC when accepting a new referral.
If the provider does not request another change
in APC during fiscal year 2014-2015, the APC is
automatically restored to the original APC on July
1, 2015.
ODP
WAIVER CAPACITY MANAGER
AE
N/A
N/A
On the following page is an example of a partial year APC change request and the process to follow from a provider’s perspective.
REISSUE DATE: June 2, 2015
Informational Packet # 028-15: REISSUE (2ND)
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APC CHANGE EXAMPLE: Provider’s Perspective
In this scenario, a licensed community home has an approved program capacity for a Four Individual Home from 7/1/2014 – 6/30/2015. The
provider had a DP 1024 on file that documented the home had a vacancy during the period 9/1/2014 – 12/1/2014. The provider requested a
change to the approved program capacity, per the settlement agreement, and the ODP Regional WCM sent the provider an APC Determination
Letter approving the APC change request.
The shaded columns, on the table below, display the changes that will need to be made to the services (procedure codes – eligible and
ineligible W codes), begin and end dates and units, in both PROMISeTM and HCSIS, to accurately reflect the change to APC. To summarize, the
provider will need to do the following in sequential order:
 Identify and void all eligible and ineligible W code claims that were originally billed to PROMISeTM from the first day of the requested
APC change through the last day billed for the current APC;
 Add the new approved services (procedure codes – eligible and ineligible W codes), associated with the APC change, to the SSD and
ensure the APC change period is reflected in the SSD;
 Add the new approved services (procedure codes – eligible and ineligible W codes), associated with the APC change, to the
consumer’s individual support plan (ISP) for the APC change period and authorized by the AE.
 Once the provider has confirmed all of the aforementioned steps have been completed, the provider should bill the new approved
services (procedure codes – eligible and ineligible W codes), associated with the APC change, to PROMISeTM.
For this scenario, the provider must bill three (3) separate claims because each claim can only contain date spanning for a calendar month.
The provider will be billing W6094 and W6095 on three (3) separate claims with each claim containing two separate claim detail lines. One
claim detail line will be for the Three Individual Home, Eligible and the second claim detail line will be for the Three Individual Home,
Ineligible. Units and the “From” and “To” date on the claim should reflect no more than a calendar month. The provider will also be required
to enter an identifier in the patient account number field on the claim. The identifier will be furnished to the provider in their APC
Determination Letter. Providers should ensure they enter the entire identifier on the claim including any letters. See the next page to view
where the patient account number field is located on both a PROMISeTM internet claim and a Provider Electronic Solutions Software (PES)
claim.
Procedure Code/
Service
Description
Begin Date of
Service
End Date of
Service
Units Billed (Day
Units)
W6096 - Four
Individual Home,
Eligible
W6097 - Four
Individual Home,
Ineligible
W6094 - Three
Individual Home,
Eligible
W6095 - Three
Individual Home,
Ineligible
W6096 – Four
Individual Home,
Eligible
W6097 – Four
Individual Home,
Ineligible
7/1/2014
7/1/2014
9/1/2014
9/1/2014
12/2/2014
12/2/2014
8/31/2014
8/31/2014
12/1/2014
12/1/2014
6/30/2015
6/30/2015
62
62
92
92
211
211
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Informational Packet # 028-15: REISSUE (2ND)
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PROMISeTM Internet Claim: Patient Account # field
Your APC approval letter
will contain the identifier
to enter in this field when
TM
submitting a PROMISe
internet claim.
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Informational Packet # 028-15: REISSUE (2ND)
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Provider Electronic Solutions (PES) Software: Account # field
Your APC approval
letter will contain the
identifier to enter in
this field when
submitting a claim
using PES software.
ODP Regional Waiver Capacity Managers (WCMs)
Name
Bill Bruaw
Mary Citko
Marie Craven
Dan Goclano
REISSUE DATE: June 2, 2015
Informational Packet # 028-15: REISSUE (2ND)
e-mail
[email protected]
[email protected]
[email protected]
[email protected]
Region
Central
Southeast
Northeast
Western
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DP 1024 Form – For Reference Only [get form at www.odpconsulting.net > Resources > ODP Forms > DP 1024 UF]
REISSUE DATE: June 2, 2015
Informational Packet # 028-15: REISSUE (2ND)
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DP 1024 Form – For Reference Only [get form at www.odpconsulting.net > Resources > ODP Forms > DP 1024 UF]
REISSUE DATE: June 2, 2015
Informational Packet # 028-15: REISSUE (2ND)
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APC CHANGE REQUEST FORM
Request for Change in Established Approved Program Capacity (APC)
PER the 2014 Provider Settlement Agreement
Name of
Provider:
MPI#:
Requested Start
Date:
Provider Name:
Contact
Person: Phone number:
Service location Code:
Service location address:
End Date (no later
than 6/30/15)
Vacancy Notification
Submitted?
Requested APC:
Current APC:
Individual(s) remaining at service location:
MCI#
Individual Name
Administrative Entity
(Registration)
SC Name and address
Administrative Entity
(Registration)
SC Name and address
Individual(s) who created the vacancy:
MCI#
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Informational Packet # 028-15: REISSUE (2ND)
Individual Name
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APC LETTER – FOR REFERENCE ONLY
REISSUE DATE: June 2, 2015
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